Behavior Research Methods, Instruments, & Computers1995,27 (2),166-168

A Windows program to assist in preparing reportsof emergency psychiatry nursing assessments

BARRY A. TANNER and RICHARD MARCOLINIDetroit Receiving Hospital and University Health Center, Detroit, Michigan

and Wayne State University Medical School, Detroit, Michigan

and

EILEENHOWELL, JESSE BATEAU, and IRVA FABER-BERMUDEZDetroit Receiving Hospital and University Health Center, Detroit, Michigan

The Emergency Psychiatry Nursing Assessment Report Framework (EP Nurse) is designed toguide the nurse through the interview-and-reporting process, and to produce a report of the nursingevaluation in emergency psychiatry in 5-10 min. Input includes identifying information, presentingcomplaints, substance-use history, medical history and vitals, psychiatric medications, treatment his­tory, history of mental illness, last hospitalization, family history of mental illness, nursing diagno­sis, and nursing intervention. EP Nurse is intended to be used by licensed nurses familiar with nurs­ing assessment in emergency psychiatry. It is suitable for adult patients.

Beginning with a desire to improve our documentationwhile protecting staff time, we decided to program a re­port generator which would ensure a consistent organi­zation and presentation ofinformation, would assist nursesin more quickly producing reports, and would reduce theburden on the psychiatrists by creating printed reportsfor them to refer to before examining patients them­selves. Prior experience with such a program for report­ing the results of psychological evaluations had demon­strated the feasability ofthis approach (Tanner, 1993).

We selected the nursing assessment for the develop­ment ofa report generator because nurses are the first tosee the patients when they arrive in our busy emergencypsychiatry service. The nurse's report not only documentsour initial contact with the patient, but ideally providesinformation for the psychiatrists and social workers touse later during the patient's stay.

The nursing staff had already developed a form to usefor their evaluations, and this was the starting point ofthe Emergency Psychiatry Nursing Assessment ReportFramework (EP Nurse). We then alternated between in­corporating suggestions from medical and nursing staffsand presenting the revised contents to key staff until wereached agreement on the data fields to be included. Onceagreement was obtained for the fields, screens were de­signed and shared with the staff; the process was then re­peated until agreement was reached on the screens andthe resulting output.

The program is organized around 10 screens or views,similar to the paper forms which a nurse might complete.

Correspondence should be directed to B. A. Tanner, Psychology 98,Detroit Receiving Hospital and University Health Center, 4201 St. An­toine, Detroit, MI48201.

The user may proceed through the views in the suggestedorder, for example, moving from identifying informationto substance-use history, or may follow whatever se­quence ofviews they wish. The user can move through thedata fields in a given view in any sequence and is able toskip fields that may not be pertinent for a particular pa­tient, without leaving obvious gaps in the printed report.

The program begins with the Main View (see Fig­ure 1). The nurse clicks on the view menu at the top ofthe screen, which drops down a list of the nine dataviews. Once the information has been entered on a dataview (see Figure 2), the user clicks on the <OK> buttonat the bottom ofthe view to accept it. The nurse can moveforward and back by clicking on the Next and Back but­tons, much as one would move about with a VCR. Mostreports will begin with Identifying Information 1 and 2,which collect demographic data. Identifying Informa­tion 2 also captures the presenting complaint. The nursewill then generally enter information about the patient'ssubstance-use history. The patient's medical history andvitals are typically entered next, followed by informationon psychiatric medications taken by the patient. The pa­tient's treatment history, history of mental illness, lasthospitalization, and family history of mental illness arealso recorded. The last data view collects the nursing di­agnoses and intervention. Clicking on <Main> returnsthe user to the Main View.

Some items are context sensitive. For example, if thenurse indicates that the patient is currently taking an anti­asthmatic, but has not identified the patient as asthmatic,a warning message box is displayed. Similarly, if valuesoutside of hospital-prescribed limits are entered for anyvital sign, a warning message box is presented. Textscrolls to allow more input than will fit within the dimen­sions of the boxes.

Copyright 1995 Psychonomic Society, Inc. 166

EMERGENCY PSYCHIATRYNURSING ASSESSMENT 167

.. ".fdlt Font Search Q.ptions Misc l.earn

• I

Identifying information Z & complaintSubstance use historyMedical history & vitalsesychiatric medicationsIreatment historyt!istory of mental illness!.ast hospitalization & family historyNursing diagnosis & intervention

Figure 1. The Main View with the view menu down.

Figure 2. The Medical lfistory and VItals View with a warning message box.

Clicking <Report> at the top of the Main View pro­duces a report that incorporates the information just en­tered (see Figure 3). That report may be edited andprinted within EP Nurse and saved to disk. EP Nurse pro­vides considerable text processing capabilities, as well as

the option of saving the file in formats that can be readby many commercial word processors.

EP Nurse was written in Visual Basic 3.0, and usesHighEdit 1.10, a custom control, to provide word­processing capability.The program requires Windows 3.0

168 TANNER, MARCOLINI, HOWELL, BATEAU, AND FABER-BERMUDEZ

'iJ Emergency Psychiatry Nursing Exam Main View (untitled) i

file Beport ~ew fdit Font ~earch Qptions Mise Learn Help

~~~:-b[:7DDEfr;'Ir~';:"-"-"-F:::I2~ ili;~ r'Y~~ ~ ~ ;t ~ :«< •

~L "' . t ., ~ l ., --.-L---,-.--.-l---, l .,.. l ..:04"" ""

EMERGENCY PSYCHIATRY NURSING REPORT

Name: Larry I. JonesID: 789654321

Identifying Information

Admit Date: December 09. 1993Birth Date: May 19. 1947

Larry Jones,came to the hospital with his brother. Hewas triaged directly to Emergency Psychiatry. Informationregarding Mr. Jones was obtained from his brother. Mr. Joneswas admitted to Emergency Psychiatry on December 09. 1993 at05:05PM. Mr. Jones is here on petition. He is not reportedto have been in police custody upon arrival here.

Mr. Jones is a 46 year old. single. White male. He isreported to have completed less than high school and he isemployed irregularly. His veteran status is unknown. Hecurrently lives alone in an apartment. Mr. Jones's phonenumber is (313) 789-4562.

Figure 3. The Main View with a report.

or later and, with the runtime library and help file, a mega­byte ofavailable disk space.

AvailabilityGraduate nurses interested in using EP Nurse should

send the senior author a letter stating that they are ex­perienced in interviewing emergency psychiatry pa­tients, that they are licensed at the appropriate level inthe state where they will be using the program, that EPNurse will be used only by or under the supervision ofli­censed nurses, and that the program will be used only fornoncommercial purposes. They should enclose a disk

formatted for their system, as well as a stamped, self­addressed disk mailer. The program will be copied ontothe disk, which will then be returned in the mailer.

REFERENCES

TANNER, B. A. (1993). Computer-aided reporting ofthe results of men­tal retardation evaluations. Behavior Research Methods, Instru­ments, & Computers, 25, 204-207.

(Manuscript received November 23, 1994;revision accepted for publication January 20, 1995.)